<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Untitled Document</title>
</head>

<body>

<form action="test_email.php" method="post" name="create_email">

<input name="email_address" type="text"  placeholder="Email address" width="500px"/>
<br />
<select name="email">
  <option value="customer_alert">customer alert email</option>
  <option value="alert_confirmation">Alert confirmation</option>
</select>
<br />
<input name="seand_email" type="submit" value="Send email" />

</form>

</body>
</html>